Provider Demographics
NPI:1750337028
Name:WICHENKUER, NIT (MD)
Entity type:Individual
Prefix:
First Name:NIT
Middle Name:
Last Name:WICHENKUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NIT
Other - Middle Name:
Other - Last Name:WICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1600 9TH STREET
Mailing Address - Street 2:ROOM 205 MAILSTOP 2-3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:3530 WEST POMONA BLVD
Practice Address - Street 2:
Practice Address - City:PONOMA
Practice Address - State:CA
Practice Address - Zip Code:91769-0100
Practice Address - Country:US
Practice Address - Phone:909-595-1221
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38312208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F17714Medicare UPIN
00C383120Medicare ID - Type Unspecified